Gait kinematics in Low Back Pain: A non-linear approach.

BACKGROUND: Kinematic analysis has been a dominant tool for addressing the neuromuscular and proprioceptive alterations that occur in Low Back Pain (LBP) patients. Movement variability is a crucial component of this analysis. In the recent years application of non-linear indices seems to be showing the way. OBJECTIVE: The aim of the study was to compare movement variability, as expressed mainly by non-linear indices, at the pelvis and lumbar spine between LBP patients and healthy participants during gait. METHODS: Sixteen (16) LBP patients and thirteen (13) healthy control subjects (non-athletes) participated in the study. Participants walked on a treadmill at different walking conditions while recorded by a 6-infrared camera optoelectronic system. Kinematic variability of pelvic and lumbar movement was analyzed using linear (standard deviation - SD) and non-linear indices (Maximal Lyapunov Exponent - LyE and Approximate Entropy - ApEn). RESULTS: Healthy subjects were found to have significantly greater mean values than LBP patients at seven pelvic and lumbar components in LyE, ApEn and SD. Specifically, the calculated LyE at the pelvis during normal gait was proven to have a sensitivity of 92.3% and a specificity of 90% in the discrimination of healthy subjects from LBP patients. Female subjects presented with higher variability in gait measures than males. CONCLUSION: Healthy participants presented with higher movement variability in their kinematic behavior in comparison to LBP patients. Lower variability values may be partly explained by the attempt of LBP patients to avoid painful end of range of motion positions. In this perspective non-linear indices seem to relate to qualitive characteristics of movement that need to be taken into consideration during rehabilitation.

A Modified Technique for Laparoscopic Spleen Preserving Distal Pancreatectomy.

Spleen preserving laparoscopic distal pancreatectomy is considered as first choice operation for symptomatic benign or small malignant lesions located at the body or tail of the pancreas. The two main surgical techniques that have been proposed and widely adopted for spleen preserving laparoscopic distal pancreatectomy are the Warshaw and Kimura techniques. A novel modified approach for laparoscopic spleen preserving distal pancreatectomy is presented. The technique was initially performed in a 57-year-old female patient with mucinous cystadenoma. Following the surgical planes created by the fascia fusion and the organ rotation during embryogenesis (fascia of Toldt and renal fascia) with the patient in a right lateral decibutus position, the tumor was accessed retroperitoneally, without dividing the gastrocolic ligament and entering the lesser sac. The tail of the pancreas was mobilized anteriorly and medially, the lesion was visually identified and resected, and short gastric and left gastroepiploic vessels were preserved. We present the technical details and tips; we define the surgical anatomy of it and discuss the perioperative course of the patient as well as the possible benefits of the proposed technique. The proposed technique seems to be safe, easy to perform, and may present a promising alternative approach for patients with pancreatic disease that can be treated by laparoscopic pancreatectomy.

Commonest overgrowth syndromes.

Overgrowth syndromes, although rare, are diagnosed more frequently lately. Major progress, such as the identification of genetic causes, has recently enhanced the delineation of the characteristic and noncharacteristic manifestations, phenotype-genotype correlations and knowledge of the underlying pathophysiologic mechanisms. This review provides a summary of the most important overgrowth syndromes aiming to familiarize the treating physician with the cardinal clinical features involved in these syndromes that encompass overgrowth, but also have a variety of other clinical manifestations (neurologic, musculoskeletal, skin, and accompanying tumors).

A comparison of the i-gel and classic LMA insertion in manikins by experienced and novice physicians.

OBJECTIVE: Airway management is of utmost importance in critical patients, for whom endotracheal intubation remains the gold standard. However, it is a difficult skill to acquire and success rates in novices are unacceptably low. Supraglottic devices constitute promising alternatives. The aim of this study was to assess the use of laryngeal mask airway (LMA) classic LMA (cLMA) and a relatively new supraglottic device, the i-gel, in experienced and novice doctors in a manikin setting. METHODS: The study population comprised 116 doctors. After a brief educational session and presentation of cLMA and i-gel, participants were randomly allocated to insert both devices in an adult manikin. Insertions were performed using a size-4 cLMA and a size-4 i-gel. The primary endpoints were the success rate for each device and the duration of the insertion attempt. Secondary endpoint was the perception of ease of use with each device. RESULTS: First attempt success rate was 90.5% for i-gel and 63.8% for cLMA (P<0.001). I-gel use reduced insertion times (13.32±4.99 s vs. 17.99±6.87 s, P<0.001) and was related with significantly higher first attempt success rates than cLMA in novices (90 vs. 48.3%, P<0.001). In addition, i-gel use provided almost equal success rates for experienced and novice doctors (91 vs. 90%, P=not significant), whereas cLMA use resulted in significantly lower success rates for novices (48.3 vs. 80.4%, P<0.001). CONCLUSION: In this manikin setting i-gel significantly improved success rates and insertion time compared with cLMA. Most importantly, i-gel use resulted in high first pass success rates for novice doctors, equal to those achieved by experienced doctors.

Cardiologists' knowledge of the 2005 American Heart Association Resuscitation Guidelines: The Athens Study.

OBJECTIVE: The study objective was to determine cardiologists' theoretic knowledge of the 2005 American Heart Association (AHA) resuscitation guidelines. METHODS: The questionnaire consisted of demographic questions, resuscitation experience questions, a question regarding confidence in resuscitation skills, and 20 theoretic knowledge questions. RESULTS: For the theoretic knowledge questions, the participants' overall mean score was 9.9 ± 4.6 (range 3-20). Participants who had received advanced cardiac life support (ACLS) training scored significantly higher. Furthermore, those who had attended the ACLS course in the preceding year scored significantly higher compared with those who had attended the ACLS course more than 1 year before the survey (19.1 ± .6 vs 16.7 ± .67, P = .001). Theoretic knowledge of resuscitation did not increase with seniority. Furthermore, no correlation was observed between the theoretic knowledge scores and participants' self-appraisal of resuscitation knowledge. CONCLUSION: Cardiologists have knowledge gaps in the 2005 AHA resuscitation guidelines. Resuscitation knowledge decay 1 year after the course is evident.

A model of hemorrhagic shock and acute lung injury in Landrace-Large White Swine.

Traumatic injury is a leading cause of death worldwide for people between 5 and 44 y of age, and it accounts for 10% of all deaths. The incidence of acute lung injury, a life-threatening complication in severely injured trauma patients remains between 30% and 50%. This study describes an experimental protocol of volume-controlled hemorrhage in Landrace-Large White swine. The experimental approach simulated the clinical situation associated with hemorrhagic shock in the trauma patient while providing controlled conditions to maximize reproducibility. The duration of the protocol was 8 h and was divided into 5 distinct phases-stabilization, hemorrhage, maintenance, resuscitation, and observation-after which the swine were euthanized. Lung tissue samples were analyzed histologically. All swine survived the protocol. The hemodynamic responses accurately reflected those seen in humans, and the development of acute lung injury was consistent among all swine. This experimental protocol of hemorrhagic shock and fluid resuscitation in Landrace-Large White swine may be useful for future study of hemorrhagic shock and acute lung injury.

Glidescope(®) videolaryngoscope improves intubation success rate in cardiac arrest scenarios without chest compressions interruption: a randomized cross-over manikin study.

AIM: The aim of this study was to assess the performance of the Glidescope(®) in a manikin cardiopulmonary resuscitation (CPR) scenario. METHODS: Following a brief didactic session, 45 volunteer doctors inexperienced with airway management, attempted to intubate a manikin using a Macintosh laryngoscope and Glidescope(®) with uninterrupted and without chest compressions. Primary endpoints were intubation times and success rate with each device. Dental compression and level of self-confidence in using each device were also assessed. RESULTS: In the scenario without chest compressions the cumulative success rate related to time to intubation was significantly higher with the Macintosh blade than with the Glidescope(®) (p<0.001). On the contrary, in the scenario with continuous chest compressions, the cumulative rate related to time to intubation was significantly higher with the Glidescope(®) (p=0.035). Significantly fewer attempts were required for the first successful intubation with the Macintosh blade in the non-CPR scenario versus the CPR scenario (p=0.007). Moreover, the number of attempts for the first successful intubation was significantly lower for the Glidescope(®) in the non-CPR (p=0.001) and the CPR scenario (p<0.001). Dental compression was significantly lower with the Glidescope(®) in both scenarios (p<0.001). CONCLUSIONS: Using the GlideScope(®) in a manikin CPR scenario provides extremely high intubation success rates in short times with the first attempt, in medical practitioners inexperienced in intubation.

A comparison of autopsy detected injuries in a porcine model of cardiac arrest treated with either manual or mechanical chest compressions.

The objective of this study was to evaluate and compare the complications of cardiopulmonary resuscitation after manual or mechanical chest compressions in a swine model of ventricular fibrillation. In this retrospective study, 106 swine were treated with either manual (n=53) or mechanical chest compressions with the LUCAS device (n=53). All swine cadavers underwent necropsy. The animals with no autopsy findings were significantly fewer in the LUCAS group (P=0.004). Sternal fractures were identified in 18 animals in the manual and only two in the LUCAS group (P=0.003). Rib fractures were present in 16 animals in the manual and only four in the LUCAS group (P=0.001). Nine animals in the manual, and two in the LUCAS group had liver hematomas (P=0.026%). In the manual group, eight animals were detected with spleen hematomas whereas no such injury was identified in the LUCAS group (P=0.003). LUCAS devise minimized the resuscitation-related trauma compared with manual chest compressions in a swine model of cardiac arrest.

Erythropoetin as a novel agent with pleiotropic effects against acute lung injury.

Current pharmacotherapy for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is not optimal, and the biological and physiological complexity of these severe lung injury syndromes requires consideration of combined-agent treatments or agents with pleiotropic action. In this regard, exogenous erythropoietin (EPO) represents a possible candidate since a number of preclinical studies have revealed beneficial effects of EPO administration in various experimental models of ALI. Taken together, this treatment strategy is not a single mediator approach, but it rather provides protection by modulating multiple levels of early signaling pathways involved in apoptosis, inflammation, and peroxidation, potentially restoring overall homeostasis. Furthermore, EPO appears to confer vascular protection by promoting angiogenesis. However, only preliminary studies exist and more experimental and clinical studies are necessary to clarify the efficacy and potentially cytoprotective mechanisms of EPO action. In addition to the attempts to optimize the dose and timing of EPO administration, it would be of great value to minimize any potential toxicity, which is essential for EPO to fulfill its role as a potential candidate for the treatment of ALI in routine clinical practice. The present article reviews recent advances that have elucidated biological and biochemical activities of EPO that may be potentially applicable for ALI/ARDS management.

Use of the impedance threshold device in cardiopulmonary resuscitation.

Although approximately one million sudden cardiac deaths occur yearly in the US and Europe, cardiac arrest (CA) remains a clinical condition still characterized by a poor prognosis. In an effort to improve the cardiopulmonary resuscitation (CPR) technique, the 2005 American Heart Association (AHA) Guidelines for CPR gave the impedance threshold device (ITD) a Class IIa recommendation. The AHA recommendation means that there is strong evidence to demonstrate that ITD enhances circulation, improves hemodynamics and increases the likelihood of resuscitation in patients in CA. During standard CPR, venous blood return to the heart relies on the natural elastic recoil of the chest which creates a transient decrease in intrathoracic pressure. The ITD further decreases intrathoracic pressure by preventing respiratory gases from entering the lungs during the decompression phase of CPR. Thus, although ITD is placed into the respiratory circuit it works as a circulatory enhancer device that provides its therapeutic benefit with each chest decompression. The ease of use of this device, its ability to be incorporated into a mask and other airway devices, the absence of device-related adverse effects and few requirements in additional training, suggest that ITD may be a favorable new device for improving CPR efficiency. Since the literature is short of studies with clinically meaningful outcomes such as neurological outcome and long term survival, further evidence is still needed.

Hydroxyethyl starch 6% (130/0.4) ameliorates acute lung injury in swine hemorrhagic shock.

BACKGROUND: Traumatic hemorrhage induces acute lung injury. The aim of this study was to assess whether lactated Ringer's solution or 6% hydroxyethyl starch 130/0.4 would have different effects on acute lung injury following hemorrhagic shock. METHODS: Twenty healthy pigs (19 ± 2 kg) were subjected to hemorrhage and were randomly allocated to two groups: Group A (10 pigs) who received lactated Ringer's solution and Group B (10 pigs) who received hydroxyethyl starch 130/0.4. Hemodynamic response and serum lactate were measured at predetermined phases. Four hours after fluid resuscitation animals were euthanized. Lungs were harvested, and tissue samples were collected. Focal thickening of the alveolar membranes, vascular congestion, number of activated neutrophils, alveolar edema, interstitial neutrophil infiltration, intraalveolar infiltration, and alveolar hemorrhage were assessed. Each feature was given a score from 0 to 3 (0 = absence, 3 = severe). The wet/dry ratio was also calculated, and with the use of Evans blue dye extravasation method, capillary permeability was assessed. RESULTS: The total histology score of Group A differed significantly from that of Group B, being significantly lower in Group B animals P = 0.048. The wet/dry weight ratio was significantly higher in the lactated Ringer's group (median [range]) (Group A, 5.1 [0.5]; Group B, 4.9 [0.3]; P = 0.009). The Evans blue dye extravasation method was utilized to study the lung capillary permeability. The animals in Group B showed a marked reduction in microvascular capillary permeability compared with the animals in Group A (Group A, 58.5 [21] mg/g; Group B, 51.5 [14] mg/g; P = 0.017). CONCLUSIONS: Our study indicates that resuscitation after hemorrhagic shock with hydroxyethyl starch 130/0.4 led to less lung edema and less microvascular permeability in this swine model.

Refined induction of anesthesia with remifentanil after bolus propofol administration in Landrace/Large White swine.

The authors report a prospective randomized blind study in which they used a refined anesthetic technique in male Landrace/Large White swine (n = 125 pigs, 19 ± 2 kg, 10-15 weeks old). The animals were first premedicated with ketamine, midazolam and atropine and then given a dose of 1, 2, 3, 4 or 5 µg remifentanil per kg body weight (dose amounts were randomly assigned) after a bolus dose of propofol. The authors assessed the intubation conditions (e.g., jaw relaxation and other parameters) 20 min after premedication and then 5 min after anesthesia induction. All animals that received each of the different remifentanil dose amounts were successfully intubated in less than 30 s. No animal developed apnea during intubation or experienced substantial reductions in heart rate or blood pressure (> 25%) between the two time points (20 min after premedication and 5 min after anesthesia induction). Overall intubation conditions were significantly better in animals that received 5 µg remifentanil per kg body weight than in animals that received other dose amounts (P < 0.001). The average time to intubation was significantly shorter for animals that received 5 µg remifentanil per kg body weight than for animals that received any of the other dose amounts (P < 0.001). The authors concluded that for this study, 5 µg remifentanil per kg body weight resulted in excellent intubating conditions in this swine breed.

Ischaemia modified albumin in the diagnosis of acute coronary syndromes.

The early diagnosis of acute coronary syndrome remains problematic, despite recent improvements. Traditionally, the diagnosis of acute cardiac ischaemia relies on the combination of chest pain, electrocardiographic changes and elevation of serum markers. Troponins are currently the "gold standard" test for the detection of myocardial necrosis, but they are unsuitable for early diagnosis, as nearly 50% of patients may present to the emergency department with non-diagnostic concentrations. Ischaemia modified albumin increases within minutes after the onset of ischaemia, remains elevated for 6 to 12h, and returns to normal within 24h. Thus, it may be a valuable aid for the clinician enabling early detection of ischaemia before the development of myocardial necrosis. Its high sensitivity comes at the expense of a lower specificity because its increase may be due to ischaemia of other tissues such as gastrointestinal tissues or skeletal muscles tissues. This paper has focuses on the cardiology aspect of this biomarker, underlying its potential value in the emergency department.

Nurses are more efficient than doctors in teaching basic life support and automated external defibrillator in nurses.

BACKGROUND: Cardiac arrest (CA) is a leading cause of death worldwide. The European Resuscitation Council (ERC) has developed basic life support/automated external defibrillation (BLS/AED) courses for uniform training in out-of-hospital CA. OBJECTIVE: The present study compares the resuscitation skills of two groups of nursing staff, one taught by newly trained ERC nurse-instructors and the other by newly trained doctor-instructors. METHOD: Eighteen doctors and 18 nurses were asked to teach a total of 108 nurses in a (BLS/AED) course. One month after its completion, all 108 nurses were asked to be re-evaluated, with the use of the objective structured clinical examination. CONCLUSIONS: No statistical significant difference between the two groups was noted in the written test, in contrast with data collected from the practice skills check-list. Nurses in group A could easily identify the patient in cardiac arrest but had difficulties concerning chest compressions and handling the AED. Nurses in group B were more focused during the performances, used AED more accurately and continued cardiopulmonary resuscitation with no delays. Nurses prove to be more efficient in training nurses.

Selective beta blockade improves the outcome of cardiopulmonary resuscitation in a swine model of cardiac arrest.

BACKGROUND AND OBJECTIVES: Epinephrine has been the mainstay drug of choice for cardiac resuscitation for more than 30 years. Its vasopressor effects favoring initial resuscitation point to its beta-adrenergic action. However, its beta-adrenergic actions may have detrimental effects. The aim of the present experimental study was to evaluate the efficiency of coadministration of Esmolol, an ultra-short-acting beta-blocker, and of epinephrine in a swine model of cardiac arrest. MATERIALS AND METHODS: Fourteen pigs (19 +/- 2 Kg) were anesthetized and instrumented. Ventricular Fibrillation (VF) was produced electrically. After induction of VF, the animals were left untreated for 5 minutes. Animals were randomized into two groups, control and study group. Six animals were used in the control group, and 8 in the study group. The control group received 10 ml of normal saline via a peripheral vein, while the study group received 0.4 mg/kg Esmolol in 10 ml dilution. Epinephrine was administered to all animals after the first unsuccessful defibrillation set, and all animals received standardized Advanced Life Support. RESULTS: Seven animals (87.5%) restored cardiac rhythm compatible with a pulse in the Esmolol group, compared to 2 animals (33.3%) in the control group (p = 0.018). The average time until restoration of circulation was 16 +/- 3.2 minutes in our control group and 12.8 +/- 1.4 minutes in Esmolol group (p = 0.059). Coronary perfusion pressure (CPP) was significantly higher in the Esmolol group. CONCLUSIONS: Esmolol improves significantly the outcome of cardiopulmonary resuscitation and the average time of restoration of circulation, while in the proposed dosage does not alter the CPP at the beginning of CPR. However, it augments CPP from the sixth minute of CPR and afterwards.